EXHIBIT A
PROCEDURE 09-08-01
December 2007
WAIVER TO RELEASE EDUCATIONAL RECORDS*
I, ___________________________________________________, hereby authorize the
[print student’s name]
________________________________ of the University of Pittsburgh to release my
[insert school or department name here]
educational record information to:
[print name(s) of authorized recipient(s)]
I understand that by signing this authorization, I am waiving my rights of nondisclosure of these
records under federal law only to the person(s)/organization(s) specifically listed. This release
does not permit the disclosure of these records to any other persons or entities without my
written consent or as permitted by law.
I further understand that I do not have to consent to this disclosure and that I may revoke the
authorization by sending a written revocation of this authorization to the University of
Pittsburgh’s ______________________________________.
[insert school or department name here]
I understand that any revocation of authority hereunder would only govern subsequent releases
and only be valid from the time of the ________________________________
[insert school’s or department’s name here]
actual receipt of a written notice.
__________________
[date]
_______________________________________________
[student signature]
Student System ID Number ________________________
OFFICE USE ONLY
Action Taken:
*NOTE:
By Whom:
Date:
A copy of this waiver or its revocation must be forwarded to the Office of the University
Registrar or Regional Campus Registrar upon receipt, for inclusion in the online student
information system.